'EBM Alone Is Insufficient'

Rx for Entire Community May Lead to Better Individual, Population Health

June 14, 2011 10:35 am Barbara Bein

Although experts agree that evidence-based medicine, or EBM, has gone a long way to advance medical practice, the health care system is not always consistent in translating those advances into improved patient health. That's the premise of a commentary in a recent Journal of General Internal Medicine(www.springerlink.com), in which one family medicine educator suggests that if primary care physicians broaden their perspective about EBM and seek to understand and overcome the barriers to health in patients' lives and communities, better outcomes in both individual and community health can result.

According to Thomas Bodenheimer, M.D., M.P.H., adjunct professor of family and community medicine at the University of California-San Francisco and co-director of its Center for Excellence in Primary Care, and his internal medicine co-author, David Moskowitz, M.D., "EBM alone is insufficient as a guiding principle for medical practice."

The correct equation, however, is simple, the two contend: EBM plus self-management support plus community health equals evidence-based health. Or, EBM + SMS + CH = EBH.

"Patients may try to incorporate EBM into their lives by making the recommended lifestyle changes, regularly monitoring their disease and adhering to their medications, but often fail because the larger deck -- their physical and social environment -- is stacked against them," say the authors.

"For example, a woman living in a crime-infested neighborhood lacking healthy food outlets, facing barriers to healthy eating and regular exercise, would have great difficulty controlling her diabetes no matter how perfectly the health care team manages the disease and teaches her the knowledge and skills needed for diabetes control."

In an interview with AAFP News Now, Bodenheimer described specific problems in one San Francisco neighborhood that hinder patients' ability to self-manage their disease.

These patients, he said, "have no grocery stores and have poor transportation out of the neighborhood. They have to rely on corner grocery stores with almost no fruits and vegetables to get food. Three fast-food outlets are not far away and they have cheap, but high-fat/high-calorie food, and they can't afford other things."

"It is a huge problem for taking care of diabetes, hyperlipidemia, hypertension and obesity."

Similar environmental and lifestyle problems confront "high-functioning business and professional people," said Bodenheimer, who included himself among that number.

"During my 32 years as a full-time primary care physician, I often had five minutes for lunch and got home at nine at night," he said. "I was on call some evenings and weekends and the stress was never-ending, causing me to eat unhealthy foods as stress reducers.

"As a physician, I understand evidence-based medicine and what is healthy and what is not, and (still) the work environment made it very difficult to practice evidence-based medicine for myself."

In his clinical practice, Bodenheimer said he focused initially on integrating SMS into the care of his patients with chronic conditions -- that is, providing them with the skills and knowledge they needed to improve their own health behaviors and adhere to medication schedules.

But, as time went on, "it became increasingly clear that due to the toxic environment in which they lived, patients trying hard to adhere to the action plans found it very difficult to do so," he said. "Thus, the need for the community health component of evidence-based health."

Family physician Mary Thoesen Coleman, M.D., Ph.D, of New Orleans, a former dean of the Ross University School of Medicine, Dominica, West Indies, and now a special adviser there, professed similar views.

"I agree that physicians need to change their framework to one of evidence-based health that embraces the kind of change needed from partnership with communities," she told AAFP News Now.

"Family physicians can and should provide information about community resources, but I think having a team of individuals in the practice who coordinate and work with the community would be an excellent model for us to adopt."

For example, Coleman added, "Some family physicians are already working with churches to help groups of people with diabetes care for each other and improve their health and disease management."

Saria Carter Saccocio, M.D., of Danville, Va., was formerly associate director of the Floyd Family Medicine Residency in Rome, Ga. While at the residency, she said, she and a team helped patients self-manage their diabetes using the Diabetes Master Clinician Program(clinical.diabetesjournals.org) (extract), a quality assurance program sponsored by the Florida AFP Foundation.

Now the chief medical officer at Danville Regional Medical Center, Carter Saccocio told AAFP News Now that physicians can incorporate simple interventions into their practices and offices that enhance the CH aspect of the EBH model.

For example, physicians can host community gardens on their property where they and their patients can reap the benefits of both the toils of gardening and the fresh produce they harvest. Physicians can participate in relays and walks with their patients. And they can encourage their local hospital to sponsor a community market with fresh fruits and vegetables.

Bodenheimer and Moskowitz discuss the same idea in their commentary, saying that primary care physicians can, indeed, help address environmental factors and disease management at the community level. Getting a patient to join a walking group is an individual intervention, they note. Promoting more safe walking paths is a community intervention. But a clinic that organizes walking groups among patients in an underserved urban area represents both an individual and a community intervention.

"Maybe we can't change the whole culture, but we need to start with a vision of what the small changes could eventually create," Bodenheimer told AAFP News Now. "My vision is of a city with no cars, with greenbelts and walkways that make walking attractive and easy, with neighborhood-based crime protection, the organization of people to walk together, lots of basketball courts and other playgrounds, and the banning of fast-food establishments in the entire city.

"That's my personal vision. A part of evidence-based health is for primary care practices to support efforts moving in that direction."