By: Randell Wexler, MD and Chris Taylor , PhD, RDN, LD, FAND
Reprinted from the spring 2019 issue of The Ohio Family Physician.
As family physicians, our concern is the total care of our patients encompassing acute needs, chronic disease management, and prevention. As such, per encounter, we will manage an average of 5.4 problems with a total work complexity per hour, which represents a 33% greater number of issues than seen in cardiology.1,2
If we were to perform all guideline recommended preventive care it would take 7.4 hours daily, with an additional 10.6 hours to complete all of the recommended chronic care.3,4 In addition to the in-room work, the amount of time required to room the patient has increased considerably as well with value-based contracting requiring screens for depression, fall risk, and cognitive function. Clearly, we have a bandwidth issue, but it can be mitigated by pursuing team-based, patient-centered care.
For most patients, we exist as the patient’s medical umbrella to optimize health, as well as prevent and treat chronic diseases. The cornerstone of evidence-based recommendations for most chronic conditions (i.e. hypertension, diabetes, and hyperlipidemia) is implementation of intensive lifestyle behavior therapy. As defined by the U.S. Preventive Services Task Force, medium- (31-360 minutes) to high-intensity (>360 minutes) lifestyle interventions are needed to produce reductions in markers of chronic disease.5
Within these complex needs during patient encounters, family physicians have been shown to spend approximately one minute on lifestyle behavior modification issues.4,6 Most physicians cite a lack of time, but also a lack of fundamental knowledge in nutrition and training for behavior change strategies as the primary barriers to addressing lifestyle behaviors. Unfortunately, however, many of us have had little, if any, nutritional education as part of medical school and residency, and for those who have it was only cursory.
In addition, nutrition is more complex than what foods are consumed. Basic education about food groups can only get us so far. Social determinants of health are playing a greater role in health outcomes, which are becoming primary drivers in an outcomes-based model of financing health care. Many patients face food insecurity, live in food deserts, and have socio-economic barriers that we have neither the training nor time to help them overcome.
These issues are more complex, when eating healthy may fall lower on the priority list than primal needs, such as choosing between rent, transportation, or medications.
Team-based patient-centered care necessitates that primary care physicians work hand-in-hand with other professionals, especially medical dietitians to leverage their and other professionals’ expertise to aid in the care of our patients. When patients experience injury and mobility issues, the primary response is to refer them to physical therapy. If other gaps in care are noted, referrals to experts should be the primary objective.
These professionals may be embedded within the office or partnered with by collaborative agreements. Fortunately, there is a group of professionals with whom we can partner to maximize our patients’ health – registered dietitians (RDs). RDs complete a science-based didactic curriculum and are required to complete 900 hours of clinical experiential learning to be eligible for the national registration examination in order to be eligible for licensure in the state of Ohio.
I have been fortunate to have a clinical RD in my office, as well as work with a research-focused RD, exploring ways to positively impact my patients’ health. In both instances, RDs have demonstrated themselves to be an important team member in improving outcomes of my patients with chronic disease.
While reimbursement for medical nutrition therapy is limited, our cost-benefit analysis shows that RDs have more than covered their costs and are a source of revenue for the department.7 More importantly, the partnerships have significantly improved diet quality in primary care patients in three visits.8 When interviewed, many of these patients expressed a concern about their lifestyle behaviors, but were not activated to make it a priority until it was endorsed and prioritized by their family physician.
As health care continues to evolve, the value-based model and its success (both with respect to outcomes and finances) require the evolution of team-based care. David Katz, MD, posits an ethical obligation of physicians to address such critical issues in patients’ health and refer to the expertise needed to address these complex issues of lifestyle behavior.9
References available online at www.ohioafp.org/newspublications/the-ohio-family-physician-references.