How physician surveys impact major issues
How many surveys have you been asked to take in the last year? Now, how many of those surveys seemed like they mattered? The Internet is flooded with surveys about anything and everything, but surveys directed toward physicians and focused on specific impact issues can actually make a difference. For the Colorado Medical Society, surveying physician members has brought a new element to advocacy efforts on major health care concerns.
Benjamin Kupersmit, president of Kupersmit Research, joined forces with the Colorado Medical Society in 2008 to conduct a survey about comprehensive health care reform. Seeing tremendous value in the survey's data, the parties continued their relationship and addressed many other issues such as network adequacy, physician-assisted suicide, Colorado's attempt at a single-payer system, known as Amendment 69, and the Aetna-Humana and Anthem-Cigna mergers.
"We've been able to use the surveys primarily to create a representative view of the voices not in the room when the board meets," Kupersmit said, "the voices of the physicians who are too busy to show up and engage in that in-person level."
"We always do some kind of a focus group with the people who are involved," he said. "And we will always open up these focus groups to whoever wants to participate." For example, when Amendment 69 was on the table in Colorado, they brought in both advocates and opponents to collect perspectives from both sides and create legitimate data that reflects the full opinion of the organization.
Surveys make a difference The society sent a survey to physician members to find out how they felt about the two major insurer mergers last year. "This survey set out to specifically create evidence of monopsony power and abuse by commercial payers as being experienced by our physicians," Kupersmit said. The critical questions in this survey were directed toward the physicians who could cite specific challenges in contract negotiations and that were hindering their ability to contract, authorize and be paid for their work.
One of the questions asked was how the mergers would affect physicians' abilities to negotiate contracts with the insurers. And about 85 percent of the physician members said it would negatively affect their negotiations. This data was critical for the society in how it approached its opposition to the mergers.
"It was very impactful," Kupersmit said. "We asked our decision makers, 'Do you support or oppose the mergers?'" They found compelling evidence that the physicians on the ground were largely against them.
Kupersmit pointed out an important part of choosing which issues to take a stance on or approach solutions to after surveying physicians. You have to look at "the balance between [strong] and soft intensity of support or opposition," he said. "When 63 [percent] strongly oppose and 16 [percent] somewhat oppose, that ratio is so tilted that we see that there's passion, and in this case fear, frankly, if this merger was allowed to go through."
With Amendment 69, the Colorado Medical Society's survey found that 67 percent of physicians across the state were strongly against the amendment and only 9 percent were strongly in favor. "What we found from our physicians is that [they] have little or no appetite … for a huge effort to restructure," Kupersmit said. And the results of this survey enabled the society to take a position on the issue.
The AMA also conducted a survey, in collaboration with the California Medical Association, which was implemented in several other states and captured physicians' opinions on the mergers. That data was sent to the U.S. Department of Justice (DOJ) and state attorneys general, led to meetings between the DOJ and practicing physicians and culminated in the opposition to the deals not only from several states, but also from the DOJ. The lesson: Physician voices have power.
Read more at AMA Wire®.
Gun violence: Use public health approach in the exam room
Counseling patients on proper firearm safety and storage comes with cultural, societal and political barriers. But when physicians focus on the well-being of their patients, risk factors and research, and use an empathetic and knowledge-driven approach, firearm safety can improve. It's not about politics. It's about keeping patients safe and healthy.
Marian Betz, MD, MPH, an emergency physician and associate professor of emergency medicine at the University of Colorado School of Medicine, has found herself "on the front lines" of firearm violence prevention through treating victims of violence in the ED.
"I'm often frustrated by what feel like really senseless acts of violence that we should be able to prevent, and people's lives shouldn't be ruined," Dr. Betz said to a crowd of physician advocates at the 2017 AMA State Legislative Strategy Conference in Amelia Island, Fla.
Dr. Betz and her colleague, Megan Ranney, MD, MPH, associate professor of emergency medicine at Warren Alpert Medical School of Brown University, provided physicians at the conference with real-world information on how to talk to patients about firearm safety and violence prevention.
"There are patients who truly fear that a physician documenting firearm access is the first step to firearm confiscation," Dr. Betz said. "So should doctors talk about guns? We would both say, 'Yes.'"
Physicians have a role to play. "Even things as simple as educating families on safe-storage methods and homes with safe storage, [and] identifying people at risk of suicide can have a real impact," Dr. Betz said.
Know the numbers When physicians are talking about firearm safety and violence prevention with patients, they should know the facts of the matter. Firearm ownership and reason for ownership—whether it's hunting, protection or recreation—can affect how a physician approaches the issue.
"Thinking about your [patients'] and what matters to them and what the firearm culture [in your area] is will be important in how you craft interventions," Dr. Betz said. The average U.S. gun-related death rate is about 10 per 100,000 people, and the rate varies by state and region, she added.
There were 33,636 firearm deaths in 2013. Of those deaths, just 1.5 percent were "accidental," while 0.3 percent resulted from mass shootings. Thirty-four percent were homicides and legal interventions, and 63 percent were suicides. "I'm not trying to imply that suicide deaths are more important," Dr. Betz said. "[But] in the national conversation about gun violence, suicide is often left out."
Safe storage of firearms could significantly reduce the number of firearm deaths because these are theoretically preventable, Dr. Betz said.
"We know that of all people with suicidal thoughts and even attempts, only 10 percent actually die by suicide," she added. "We know when people attempt suicide with a gun, about 90 percent of them die … and that final decision is often impulsive."
The right questions to ask "We talk about smoking. We talk about family history. We talk about diet. We talk about blood pressure management," said Brown's Dr. Ranney. All of which have risk factors that lead to those discussions. There are risk factors that indicate someone has an increased risk of experiencing a firearm-related injury and they can be addressed through interventions that could potentially stop a shooting from happening.
"Unfortunately, due to the lack of research our knowledge of what those risk factors are is still very broad," Dr. Ranney said. For example, citing the recent violence in Chicago over the holidays, Dr. Ranney said, it's known that interpersonal violence is contagious. "After there's one shooting there's more likely to be another," she said. Another recent JAMA Internal Medicine study found that "social contagion" accounted for 63.1 percent of 11,000-plus Chicago acts of gun violence analyzed between 2006 and 2014.
When speaking with patients and their families, physician counseling should be individualized and routine, Dr. Ranney said, "so that they're not feeling singled out … but, rather, that you're taking into account the reasons for owning a firearm" and how to keep them safe.
Examples of the right questions when patients are at risk:
- "What do you think about storing your guns offsite until the situation improves?"
- "Have you thought about how to keep your kids safe around your guns?"
- "Let's talk about how to lower the risk of your boyfriend hurting or killing you."
- "I'm not saying you have to give up or dispose of your gun; we're talking about safety."
Having the conversations in an individualized, empathetic, but orderly spirit actually does work, Dr. Ranney said. Research has found that families given brief counseling and a trigger lock by a pediatrician are significantly more likely to use them. Emergency department and trauma service interventions can lower the risk of future fights and weapon carriage. Families of suicidal teens may lock up their guns if counseled appropriately.
Read more at AMA Wire.
