Vol. 88 April 15, 2013 How Do You Feed a Baby in a Patient-Centered World?

April 14, 2013

hub “Patient-centered medicine” is one of the new buzz words in health care reform. It is second only to “medical home”; the label for the multi-disciplinary team incentivized by governmental reimbursement to use electronic technology to provide the coordinated, individualized primary care that the family doctor used to provide by himself (yes, it was usually a “he” back then).

“Patient-centered medicine” champions joint decision-making between physician and patient. Most illustrative examples of patient-centered medicine given are high cost, high drama events like alternative cancer treatments, cardiac interventions, and even DNR or “keep plugging” choices. The central tenet is that the patient knows best his or her needs, desires, and feelings and medical decisions should consider those as paramount.

  • Pediatricians recommend breast feeding exclusively for at least 6 months, ideally for 12 months. (1)
  • Nearly half of mothers started solids at age 4 months to 6 months so the infant would sleep through the night and/or they would spend less on expensive formula. (2)

How might “patient-centered medicine” sound when it comes to “feeding baby”?
We pick up the conversation near the end of a routine well-baby visit:

PHYSICIAN SITS CLICKING ON A LAPTOP BACK TO BACK WITH THE PARENT WHO IS DIAPERING AND DRESSING HER INFANT ON THE EXAM TABLE.

PHYSICIAN: Leonard is 4 months old so he’s due for his second round of immunizations today. Before we give those, do you have any other questions?

PARENT: He’s not sleeping through the night. I want to start some solid food. Is there any food I should avoid?

PHYSICIAN: Are you still breast feeding?

PARENT: Well…sort of. I went back to work when he was 2 1/2 months old. He gets formula at daycare, and I breast feed him at bedtime.

PHYSICIAN SWIVELS AROUND ON STOOL TO FACE MOTHER.

PHYSICIAN: As I am sure you know, we recommend breast feeding for the first year.

PARENT: R-i-g-ht… well I had to go back to work. Doesn’t breast feeding make him plumper and more likely to be fat as he gets older?

PHYSICIAN: Breast feed babies sometimes look plumper than formula babies, but we think breast feeding actually protects them from adult obesity.

PARENT: Really? I heard on Fox News last month that breast feeding didn’t actually do that. (3)

PHYSICIAN: Yes, that was a recent single study done in Europe. The NY Times and Time magazine also carried it. (4)

PARENT: Emma certainly isn’t fat. I remember I breast fed her for close to a year because I wasn’t working at the time. You told me not to start her on solids until after 6 months.

PHYSICIAN: Just a second. Let me look up Emma’s record. …

PHYSICIAN SWIVELS AROUND ON STOOL TO TYPE ON THE LAPTOP.

PHYSICIAN: What’s her birthdate?…our new computerized medical record keeps records only as individual patients, not families. I can’t find Emma’s record.

PARENT She’s eleven now, from my first marriage, her last name is different.

PHYSICIAN: Ah, yes, here she is. …Looks like we were concerned about your family’s history of food allergies, so we cautioned you about not starting foods until she was over 6 months old.

PARENT: Emma is doing great without any allergies. I’d like to start solids on Leonard because he is so fussy at night and seems hungry when he wakes up.

PHYSICIAN: A new recommendation is to start potentially allergic foods earlier rather than later . Small portions of those foods started as early as 2 months of age may actually reduce future allergic reactions. (5)

BEEP…BEEP…BEEP

PARENT: What’s that?

PHYSICIAN SWIVELS AGAIN TO FACE PARENT.

PHYSICIAN: Oh, that’s just my laptop letting me know that this visit is reaching 95% of the usual duration of a well baby visit.

PARENT: So, I should breast feed Leonard for a whole year, but could have started solid foods two months ago? Most of my friends swear that giving food makes their babies sleep longer at night.

PHYSICIAN: Exclusive breast feeding for 6 months has lots of advantages for the infant. There is no evidence that giving solid foods makes the infant sleep longer at night, but there is probably no harm in starting him on cereal now.

PARENT: Any particular kind of cereal?

PHYSICIAN: A 1994 Swedish study showed that introducing wheat before 6 months of age caused a big spike in gluten allergies and celiac disease, but a recent one there showed that giving wheat to breast fed babies at 4 months actually decreased the later occurrence of celiac disease and gluten allergy.

PARENT: So, wheat cereal could be either good or bad at his age? This is very confusing.

PHYSICIAN: Science can be confusing. It often changes its mind as new data is gathered.

PARENT: When I switch to all formula is there any one that is best? Should I start with soy? When I switch to milk, should it be whole milk? … or 2%? … or 1%? What about peanuts?

BAHUGGA!…BAHUGGA!…BAHUGGA!

PARENT: What’s THAT?!

PHYSICIAN: That’s a notice for me that the average duration of a well baby visit has been exceeded by 20%. I really must go on to the next patient. Please go to our practice website where we answer those questions and provide several nutritional advice sites for further information.
Your baby is doing fine.  We’ll see you again in two months.

PHYSICIAN EXITS THE EXAM ROOM AND PARENT STICKS HER HEAD OUT INTO THE HALLWAY TO DIRECT ONE MORE QUESTION TO HER RETREATING BACK.

PARENT: Oh, doctor….do I need a password for the website?

References:
1. American Academy of Pediatrics, AAP.org
2. Journal of Pediatrics, March 30, 2013
3. Fox News March 13, 2013 reporting on JAMA article March 12, 2013
4. NY Times March 14, 2013
5. American Academy of Allergy, Asthma, & Immunology, January 2013

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Vol. 38 February 1, 2011 Health Care Reform in the U.K. and U.S

February 1, 2011

 

“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw

In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.

Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.

Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996,  such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.

Accountable Care Organizations (ACOs)
In the U.K. regional Primary Care Trusts (PCTs) have been responsible since 1948 for “commissioning” (purchasing) care beyond primary care; hospitals, specialists (consultants), ambulance service, maternal health. GPs advised these trusts, but did not run them. By 2013 they will. 141 GP Consortia will commission (purchase by contract) all patient care services for a defined population and will control the allocation of 80% of the NHS budget. Secondary care providers (hospitals and consultants/specialists) will be competing on quality grounds for the contracts. Prices will remain regulated nationwide by the NHS. Sounds like a physician-run Accountable Care Organization (ACO) doesn’t it? (Remember 50% of U.S. medical care services are currently paid for by our government; Medicare, Medicaid, VA, or Federal Employee Health Benefits).

Medical Home
Since most GP practices have been closely connected for years with visiting home care nurses, social workers, and other ancillary social services through the Local Health Authority and every patient needs to “register” with a GP, GP practices closely match the newly-coined U.S. definition of “A Medical Home”; i.e. a multidisciplinary primary care unit that manages, but does not provide, all aspects of the patient’s care. Now the GP referrals will more directly affect the flow of money.

HIT Investment
A $20M (million) program started in the U.K. in 2003 to develop digital patient records and hospital administrative systems outsourced to two national major vendors its imhas been poorly implemented  . The new plan calls for incentives for more local and regional initiatives from the Trusts/Consortia to move HIT along.
“Improving IT is essential to delivery of a patient-centered NHS”..a modular approach based on”connect all” rather than “replace all”.
The government proposals call for an NHS-wide “information architecture” set around standards, improvements in data accuracy, and the opening up of records to patients online. The NHS looks to saving $32B (billion) by 2015 by implementation of the revised HIT plan. There is a concern about the Trusts/Consortia having enough HIT expertise to do this is. In the U.S. the establishment of 70 Regional Extension Centers and HIT Workforce Development Grants will help implement the “meaningful use” of HIT. Neither the U.K. nor the U.S. plans have established national standards for connectivity; standards that need to be “transparent and centrally mandated” to reduce complexity. This lack of connectivity will be an increasingly vexing problem for both providers and patients in both countries.

Bottom line: Both U.S. and U.K. are evolving toward a similar mixture of public/private health care schemes from their different historical directions. They share common objectives and common problems., and neither country is finding the path to be particularly smooth. Since EVERY country’s health care system is different, and critics of health care reform on both sides of the Atlantic are whipping up fear of the “other system”, it is time to move on and expand our vision by trying to learn more from France and Germany’s experiences.

References:
1. Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.”  J Med Educ. 1968, Jan;43(1):36-41.
2. David J. Kerr, M.D., D.Sc., and Mairi Scott, M.B., Ch.B., “British Lessons on Health Care Reform” , September 9, 2009, at NEJM.org
3.Wachter R, Goldman L. “The Emerging Role of ‘Hospitalists’ in the American Health Care System”. N Engl J Med 335 (7): 514–7. 1966


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