COMMENTARY

The World According to the General Practitioner

An Interview With Dr Nicholas Fiebach

Henry R. Black, MD

Disclosures

December 21, 2015

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Editor's Note: Nicholas H. Fiebach, MD, professor of medicine and vice chair for Graduate and Continuing Medical Education at Columbia University Medical Center NewYork-Presbyterian Hospital discusses the concerns of the primary care physician with Henry R. Black, MD. The interview was recorded after the topline results of the SPRINT hypertension trial had been reported but before the full data were presented and published.

Dr Black: Hi. I'm Dr Henry Black. I'm an adjunct professor of medicine at the New York University (NYU) Langone School of Medicine, and I'm here today with my friend and colleague, Dr Nick Fiebach.

Dr Fiebach: Hi, Henry. I'm a general internist. I'm a professor of medicine at Columbia University Medical Center, where I'm the vice chair in the Department of Medicine for graduate and continuing medical education.

Dr Black: What are the things in cardiology, and in general, that are of concern for generalists nowadays?

Blood Pressure After JNC 8 and SPRINT

Dr Fiebach: I think numbers one and two on my list would be screening for cardiovascular risk factors, especially blood pressure and cholesterol, which had become fairly straightforward and routine—and then the long-awaited report from the Eighth Joint National Committee (JNC 8)[1] came out and was a bit of a wrinkle, and there were reports in the New York Times[2] that wrinkled the picture even further.

Dr Black: And then we got SPRINT,[3,4] which confused—didn't confuse things, it straightened things out because I think, as I've said, that the JNC 8 made a lot of mistakes. So how do you approach screening for blood pressure now?

Dr Fiebach: It used to be that we would measure several blood pressures, and if someone was persistently greater than a blood pressure of 140/90 mm Hg, we would initiate treatment, and we would use those thresholds as our target for treatment. That was pretty straightforward, and then JNC 8 came out and suggested that we could relax, at least in terms of the systolic blood pressure, for patients who are older than 60. Even more perplexing was that the targets for people with diabetes and chronic kidney disease were also relaxed to the general population standards of 140/90 mm Hg, over 150/90 mm Hg.

Dr Black: It's interesting. Some of the people who did that (and I was not on that committee) demanded "evidence-based" guidelines—and there was no evidence whatsoever that 140 or 150 was really any different. They said that we hadn't shown that 140 mm Hg was better than 150 mm Hg. Well, now that's been shown. How have you changed what you do based on the new SPRINT study?

Dr Fiebach: The SPRINT study is very perplexing because it hasn't appeared in the scientific literature yet. [Editor's note: This interview was recorded before the findings were published in The New England Journal of Medicine.] I personally am always somewhat skeptical of new studies that advocate tighter treatments because in practice we often find that escalating medicines to achieve those thresholds causes side effects. I'd like there to be very solid justification before doing that, and I'd like to take a look at the harms as well as the benefits.

Dr Black: In the old days, we used to see many patients in the hospital with stroke. That's become a rare thing these days with more therapies, more appreciation, and more understanding, and we in the blood pressure community would like to take some credit for that. But I was afraid that by relaxing those recommendations, we'd go back to the days of seeing people with stroke. The ACCORD[5,6] study, which a lot of people were basing it on, didn't show any benefit for the primary endpoint, which was cardiovascular disease, myocardial infarction in particular. That wasn't significant, but there was a significant reduction in stroke. I'm not surprised, then, that we'd be getting to see a different look at the same thing.

So how do you screen a new patient who is maybe hypertensive, maybe not? What do you do?

Dr Fiebach: My initial approach is to check their blood pressure in the office. As you know, often that's somewhat elevated, especially on a first visit. I like to measure it myself as well as using the automated measurement by the nurse. And then I like to see, unless it's quite high, on a second and third visit. It's so easy now for patients to get their own blood pressure monitors for home that I often have patients check their blood pressures at home and use a slightly more stringent standard for home blood pressures than office blood pressures.

Cholesterol, After the AHA/ACC Guidelines

Dr Black: What do you do about cholesterol?

Dr Fiebach: Well, cholesterol is troubling too. It used to be that we had specific cholesterol targets—we could calculate what risk group a patient was in, and then we would treat to the target, using higher-potency statins if a patient was farther away from the target. And then the new American Heart Association/American College of Cardiology guidelines[7] and their calculator came out. All of a sudden, most patients who are over the age of 50 who are seeing primary care doctors have statins indicated. That's troubling at the moment because many patients who didn't think they had a cholesterol problem, and even some who don't have other risk factors, now seem to have statins indicated.

Dr Black: Being that older age is the most potent risk factor for cardiovascular disease, it's not surprising.

Dr Fiebach: Absolutely. Age seems to drive a lot of these. I just saw a man a few days ago who has mild hypertension. It's well controlled on a single medication. He's in his 70s, and when we put him through the calculator, a statin was indicated. That was a great surprise to both him and to me.

Dr Black: What did you do?

Dr Fiebach: We talked about whether he would want to be treated. He's going to think about it, and we'll see what mutual decision we make at his next visit.

Dr Black: What does he eat?

Dr Fiebach: That's a good question. He's not obese; he's slightly overweight.

Adherence: The "Submerged Iceberg"

Dr Black: You're often the first contact physician faced with this. How much of your time do you think you spend counseling vs talking into a computer?

Dr Fiebach: That's a pertinent question too. I try not to talk into the computer very much at all, although it sits on my desk. It depends on how well you know the patient, how long they've been coming to see you, and what the status is of their health problems. There are visits when I spend the entire visit, 15-20 minutes, which is a long time for a visit now, talking exclusively about lifestyle factors, diet, exercise, and medication adherence—which is the great submerged iceberg in all of this.

Dr Black: It's very hard sometimes, and people don't always tell you the truth about whether they actually take their medicine or take it as prescribed.

Dr Fiebach: I think that's absolutely right. There's a great reluctance to come clean with your doctor.

Dr Black: Well, you don't want to be embarrassed by not following orders.

Dr Fiebach: Absolutely not. I think there's also a great reluctance to express skepticism about medications. There's a lot of folk wisdom in the community about the benefits and especially about the harms of medications. As you know, statins have a terrible reputation in many communities. There are rumors that they cause liver disease, although that's been largely disproven now, and many patients are loathe to take them, although they're very reluctant to refuse the prescription or to tell the doctor they don't really want to take it.

Dr Black: Looking for any excuse not to take medications seems to be a common problem that we have to deal with.

Dr Fiebach: And in a way, that's one of the detriments of the new guidelines, which is: calculate a risk, choose a statin, and you're done. Whereas, in the old days when we treated to target, there was more of a monitoring function built in to periodically check. And if the patient wasn't at target, the first question always was: Are you taking your statin?

The Annual Physical

Dr Black: How do you screen for other issues? What do you think of the annual physical?

Dr Fiebach: You're asking me great questions, Henry. As you know, in the current environment, the American College of Physicians has put the annual physical on its list of "do not do procedures" for high-value care.[8] And I think it's certainly true that there are many aspects of the physical exam that have not been shown in a sort of rigorous way to reduce significant outcomes. But I think this may be an example of: The absence of evidence is not evidence of absence of benefit.

I think many of us who have been doing this for some time realize that there's enormous value in the doctor/patient relationship in periodically addressing a patient's health and their physical status from top to bottom. You do occasionally discover something. The rate is low, but it may be so low that it would be impossible to demonstrate a benefit of doing something that's relatively noninvasive, convenient, may have other psychological benefits, and in the occasional case could be life-saving.

"Clinimetrics"

Dr Black: I know we used to do very extensive physicals. For hypertension, I liked to do a directed physical where I looked at the organs, the findings that were directly relevant to cardiovascular disease—listen long in the belly for a bruit, or in the neck for a bruit. But what happens: You hear a murmur or don't, and the echo shows you one. Those are things that I would like to see.

Alvan Feinstein, our old colleague, got interested in what he called clinimetrics by working at a rheumatic fever hospital that NYU had back in the forties and looking at the charts. Visit one, there was a murmur; visit two, there was no murmur; visit three, there was a different murmur. So he started to focus on how accurate those charts were and devised clinical epidemiology, which is something that we all depend on. But that began with a smart person observing that things didn't necessarily make sense.

I remember when I was taught about what to do with working up the GI tract—the recommendation was everybody got a GI and a barium enema. That's what you did to everybody, healthy or otherwise. I don't think we really do that much anymore.

Dr Fiebach: I think, unfortunately, as physical exams have somewhat fallen into disfavor and the availability of imaging technology has become more and more widespread, that the sort of sophisticated approach to the exam, and knowledge of the limitations and sensitivities and specificities of findings is also being lost. But I think it's entirely possible to do a careful exam, find an abnormality, and make an educated decision about whether it needs follow-up or not.

Students and Residents

Dr Black: You interact with students and house staff.

Dr Fiebach: I do.

Dr Black: How do they approach this? What do you tell them? What do they tell you back?

Dr Fiebach: Medical students and residents going into internal medicine still spend the majority of their learning and training time in the inpatient setting, where serious diseases are much more prevalent, where the consequences are much more obvious, and the biases that operate to make one think that murmurs are likely to be terribly significant, that findings are likely to be very dire, are in place. Part of our job, particularly in their clinic rotations, is to get them to have a sense of perspective and to get them to be able to understand denominators well as the cases that end up in the hospital.

Continuity of Care

Dr Black: I know it used to bother me that the people who usually are seen in a medical school clinic or a hospital clinic change providers every 2 or 3 years. These are the very people who need continuity of care and don't really get it. Can you fix that, do you think?

Dr Fiebach: I don't know, Henry. I was the residency program director at Columbia for 5 years, from 2003 to 2008. It's quite a dilemma to think about how to balance the need to train young physicians in ambulatory medicine and the needs of their patients. I think it's a dilemma that's soluble. Many patients who come to our residents' clinics, if they had to seek care elsewhere, would get a lower quality of care. These are very smart people who are very dedicated and have lots of oversight from very experienced faculty.

On the one hand, one of the joys of being a primary care physician is longitudinal care and getting to know your patients. One of the hardest things I've had to do is when I moved twice from one institution to another, and I had to say goodbye to my long-term patients. On the other hand, 3 years is a long time, and you can forge a meaningful relationship, both the patient with their doctor and the doctor with their patient.

One of the things I did when I was residency program director was to convene a series of focus groups with patients from the community who had their care there. We were focused, at that time, more on inpatient care. What we wanted to know was: When we were encouraging bedside rounds—that is, bringing the whole team to the bedside for case presentations—was that really okay with the patients? What was it like to have this cadre of white-coated people standing around you talking about your medical care? And almost unanimous among the patients who spoke with us was their support for that model and for medical education.

I remember one patient said it best. She said, "Listen, I know that when I come to this hospital, because I'm a member of this community and when I get sick this is where I'm going to end up—when I come in 10 years, I want the doctors who take care of me in the future to be very well educated. So I'm glad to see that you're training them well now."

Nurse Practitioners and Physician Assistants

Dr Black: I'm happy to hear that. Do you use advanced practice nurses at all, or what's the role of the nurses and nurse practitioners or physician assistants (PAs) in your system?

Dr Fiebach: On the inpatient side, we use PAs very extensively. They're almost as numerous if not more numerous than house staff in our modern teaching hospital. I think the role of nurse practitioners is still yet to be worked out completely. I've worked with fabulous nurse practitioners, and I have a tremendous amount of respect for them, but nurses and physicians still, to some extent, live in separate silos. Nurses typically report to nursing directors, even nurse practitioners, and doctors report up our chain of authority and command. I think that we still have a ways to go to establish well-functioning, truly interprofessional teams, especially in the ambulatory setting. I think that's the natural place to do it. I think having parallel pathways where nurse practitioners take whoever comes in doesn't work because lots of internal medicine patients now are quite complicated, and that's not the strength of nurse practitioners. On the other hand, there is a lot of preventive medicine and treatment of minor episodic illnesses that nurse practitioners may even be better positioned to take good care of.

Electronic Medical Records

Dr Black: There has been some reasonable criticism of late, pretty vile, vigorous criticism, of the electronic medical record (EMR). I basically stopped seeing patients a little while ago, and that put me over the top because I like to spend time talking to the patient, not to the screen. And it was pretty hard to do both. How much do you use EMRs now, and what do you think about them?

Dr Fiebach: I use EMRs exclusively because that's the way we take care of patients now, not only at top medical centers but now almost throughout the medical care system and now almost by directive. The federal government has directed that medicine move completely into EMRs. There are some great benefits, and I really like some of the advantages. To be able to put your eyes on lots of information about the patient, even extending back 9 or 10 years ago, is very, very helpful—to be able to access simultaneously what many different providers think about patients.

The problem is that the EMRs for the most part seem to have been developed by designers whose primary interests have been in the administrative and financial aspects of medicine.

Dr Black: The billers.

Dr Fiebach: And not by people who have a real feel for how to put integrated information in front of the eyeballs of doctors who are taking care of them. And that's very frustrating. It's not an efficient system.

Dr Black: I know a lot of the criticism, including my own when I was doing that, was that this seemed to have been written for people who did the billing, and there are some recent articles I've read that confirm that. It's not written for the people taking care of patients.

Dr Fiebach: No, it's absolutely true. And the folks with the second biggest stake in the EMR are the regulators. So it's very easy to put points in the EMR that you can't pass without responding to the latest regulatory requirement, "Yes I did this, no I didn't do it." The result has been that to get through a patient encounter and document it takes much longer than is really necessary.

Dr Black: I recall once, where on the first visit you put your whole list of things you can think of that belong there. And then on the next visit, you're asked for the diagnoses again. One of the choices was not "the same as last time." That would have saved checking off everything, or going through everything, or only listing one where somebody could say, "Well, what happened?" You said this was a complicated patient. They only have one simple diagnosis. How come? So those are things that easily could have been changed.

Dr Fiebach: That's the Achilles heel of most medical records, particularly in academic institutions and training institutions like mine. Typically, when I start a note on a patient, I take portions of my last note, the problem list, the medication list, and import them into my current note, so-called copy and paste.

The problem is that anybody else seeing the patient, if they don't want to take their own history or verify the med list, can copy and paste notes, and that's a huge problem. On the one hand, we want to discourage it; on the other hand, if, as some people want to do, that function is eliminated, it's going to take me even longer to get relevant data in about my patients.

Dr Black: It's like so many things we try. It's got its good and it's got its bad.

Dr Fiebach: I think that's true.

The Future Role and Scope of the Generalist

Dr Black: What do you think the main issues facing generalists in the future are going to be?

Dr Fiebach: I think we've already touched on some of them. One is going to be: What's the role and scope of the generalist, particularly in internal medicine? What's the general internist going to do? Are nurse practitioners going to be seen as people who are equivalent to general internists, particularly in the outpatient area? Are general internists going to be able to retain what's been a traditional role as a coordinator of care? Are they going to be reduced to sort of bureaucratic gatekeepers, just people who are seen as restricting expensive consultations? Are they going to be replaced by telephone medicine, and decision aids and computers, and mid-levels? I think that's probably one of the biggest challenges facing general internists.

A second challenge is related—there's been such an explosion of information, and although we have great tools to manage information, it seems in the modern arena it hasn't helped that much, even about some of the things we've talked about. So new guidelines have come out, but there are questions about them. And for a dedicated general internist sent to delve deeper and try to decide for herself or himself, what's the evidence? Should I really adopt this new guideline? Should I wait? How should I modify it in select cases? Putting your hands on the right information and digesting the information is becoming more and more difficult as there are so many streams of information coming at you.

Limiting Time on Service

Dr Black: What do you think about limiting the time a house officer can be on service, making them go home? I think, in some ways, we're training people to walk out on sick patients, and that really bothers me.

Dr Fiebach: It's a real concern. In a way it's because I guess in our inertia and tradition and maybe arrogance that the way we did it is the way it should always be done, I think we turned a blind eye to excessive work hours. I think it's certainly true that it's not good for human beings or their patients to work beyond the point of fatigue. And I think that because we hadn't addressed it within our own profession, then the outside regulators pushed by famous court cases and incidents sort of gave us blanket rules, one-size-fits-all rules.

Does it make sense to limit hours? Yes. Does it convey an impression to trainees that their dedication is to the clock and not to their patient? No. Working beyond 24 hours on a given night when your patient is sick and crashing and you know them best or their relatives have just arrived and want to talk to the doctor who knows them best—that's certainly defensible. If you're in a system where that happens day after day and week after week, that's not defensible. The accreditation body for graduate medical education, the ACGME, is actually beginning to recognize that and moving in the direction of modifying its rules so interns can't work for more than 16 hours, but more advanced trainees can still work longer shifts. That seems appropriate.

There are exceptions now for individual patient circumstances that warrant a doctor staying on in the service of her or his patient or for particular educational opportunities. I think that's particularly true for surgical trainees.

An operation that's not done much that comes up at hour 23 of your 24-hour shift, that person should at least be able to scrub in and watch if not do the operation themselves. And then there's very exciting news on the horizon. The ACGME has actually sanctioned two randomized controlled trials of work-hour limits, one for surgical programs and one for medical programs. And they're underway. We won't have the answers for several more years, but that should help too.

Dr Black: I think that would be a great idea because we test everything else, we want evidence—we've got to get evidence on how we operate as well.

Dr Fiebach: Absolutely.

Dr Black: Nick, I want to thank you very much for your time. Go back and take care of patients and train the doctors of the future. It's really been a pleasure. Thank you.

Dr Fiebach: It's been my pleasure too, Henry. Thank you.

Disclosure: Nicholas H. Fiebach, MD, has disclosed the following relevant financial relationships: Received income in an amount equal to or greater than $250 from: St. Vincent's Hospital, Bridgeport, Connecticut

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