COPD: An Individualized Approach to Medication and Delivery - Episode 4
Peter Salgo, MD: When you take a look at this whole problem, not everybody out in the real practicing world is a pulmonologist or a pulmonary expert. In fact, primary care is where all of these people begin to encounter the health care system. So, is it just the physician? Is there a team involved? Who’s involved in the management of chronic obstructive pulmonary disease (COPD) out there in the texture of the real world?
Antonio Anzueto, MD: Health care providers, in general—from the person who is the first contact in the office, to the physician assistants, to nurse practitioners. Everybody’s a part of the team. As Barbara emphasized, we have to change our concept of, “Oh, I’m looking for COPD in a 75-year-old male who smoked.” Forget about it. You have to look for COPD in the 50-year-old woman who happened to smoke previously but doesn’t smoke anymore. She is coming in with a cough. You have a diagnosis with sinus, with allergies, and with this and that. You have to do a spirometry.
Peter Salgo, MD: Does this work in the real world, Byron? Do all of the primary care doctors get a team together to do this? If not, why?
Byron Thomashow, MD: Well, I think Barbara could answer some of those questions. The thing I would stress is that most COPD exists in the primary care setting. Those of us who are pulmonologists, particularly those of us who work in academic medical centers, see a very skewed population. Most of the people that we see are frequent exacerbators who, after bothering their primary care physician enough, say, “Well, I’ll go see someone else.” I don’t see very many of the nonfrequent exacerbators until they’ve reached the point that they need to be evaluated for lung volume reduction surgery, or chronic oxygen, or lung transplant. So much of COPD is in the hands of primary care. Increasingly, with limited time that you can spend with your patients, I think we will be seeing more of a team approach that potentially involves more respiratory therapists and other things.
Peter Salgo, MD: Barbara, who else do you pull in? Respiratory therapists seem like a natural choice. Obviously, the primary care physician is steering the ship—at least at first. What other specialties do you want to pull into this team?
Barbara P. Yawn, MD, MSc, FAAFP: In rural practice, which was where I was for many years, it’s great to have a respiratory therapist. There’s one over at the hospital, which is 20 miles away. Most primary care people do not have respiratory therapists in the outpatient setting.
Peter Salgo, MD: That’s what I was getting at. It’s wonderful to say, “I want all of these things,” but…
Barbara P. Yawn, MD, MSc, FAAFP: Right, but you don’t have them. When you talk about a team, maybe my team was more likely to include the receptionist and my medical assistant. I couldn’t afford nurses, so I didn’t have very many RNs. Maybe there was 1 for every 15 or 20 doctors. And many nurse-practitioners and physician assistants in primary care are practicing independently, especially nurse-practitioners. They’re out all by themselves now. I think there is a great opportunity for education. As you know, most residents in primary care don’t get a lot of time with COPD. A lot of these other people have had no education in COPD at all. We have a long way to go, to help support what they’re doing.
Peter Salgo, MD: What I’m hearing is that there are a lot of little silos here. There’s primary care, there’s the nurse practitioner, and maybe there’s some sort of respiratory therapist somewhere in the vicinity. Maybe there is not. By the way, where do the pharmacists fit in with all of this?
Barbara P. Yawn, MD, MSc, FAAFP: Pharmacists could be very, very helpful, but they’re also extremely busy. You talk to them and they say, “Well, I really don’t have time to even talk to the people because I have to check through all of these prescriptions.” A lot of pharmacists, unfortunately, are still forced to stay back behind the counter. They really never encounter patients at all.
Peter Salgo, MD: We work with PharmDs in my intensive care unit. We’ve been doing it for over a decade. We have seen a dramatic change for the better.
Barbara P. Yawn, MD, MSc, FAAFP: In primary care, we’re extremely envious of all of that. Sometimes, that’s why we send the patient off to our academic colleagues. We believe that you’re going to have more time with the patient. You’re going to have other resources to educate the patient and support the patient. It is very difficult, even when they get in the hospital nowadays. They’re in the hospital for 3 days, and they’re pretty sick during the whole time. It is difficult to get that education in.
Peter Salgo, MD: If we know that all of these specialties working together could be better than any one of them individually, and we think there’s real synergy here—whether it’s the pulmonologist plus the respiratory therapist, plus the primary care physician, plus the pharmacologist—what’s the path from here to get everyone to work together as a team?
Antonio Anzueto, MD: I think we need to engage in education with what we call “mid-level providers.” I love when they invite me to the nurse-practitioner or physician assistant meetings. I know that I will give a talk, and it will take me another hour and a half to get out of that room. The number of questions asked is unbelievable. They are on the front line every single day. People who are online say, “I have patients with ‘this’ disease. How do you do this?” So, there is a huge need to reach out to these individuals, to teach them. This is not only the case with COPD, but with many other conditions as well.
Barbara P. Yawn, MD, MSc, FAAFP: You ask, “What do we need to do?” It’s not just that we would like to have a team. I’d love to have a team. I’d love to have that time. It’s called reimbursement. If you are not getting paid for all of these other things, it’s very difficult to take that chunk out of your salary, or whatever. So, health systems. Some of them have learned very well how to do this. They do it very well in the inner city or metropolitan areas. But, when you get out to the smaller practice, it’s not done so well.
So, telehealth. I’m going to put a plug in for telehealth. We always think that telehealth means a physician seeing a patient. Telehealth can mean a respiratory therapist educating a patient, a nurse educating a patient, or a social worker or a psychologist interacting with a patient. So, we can do this. We just have to be creative.
James F. Donohue, MD: The use of high-quality media educational materials could potentially have a much greater effect. We really all care about the patient here. That’s the focal point. All of the other interactions are secondary. But, what’s the best way to get to that patient in his or her environment? What kind of media do they seek? What kind of information do they seek? What’s the best way of communicating? I think that high-quality education, with all of the innovation that’s going on in our country, could be useful.
Now, one of the problems with COPD patients is that their literacy hasn’t been the highest in the world. They’re very similar to patients with diabetes. I was always involved in education. Between the National Institutes of Health and others, we used a lot of picture books. The patients didn’t have high literacy to read how to use therapies. And when you say that the patient is given 3 inhalers, and the pharmacist and doctors are too busy—nobody’s training them. You hand them information that they can’t read very well. It tells you about the need to use apps, pictures, videos—all of the various, sundry things to make sure that the patient successfully gets the necessary drugs and puts them into their body.
Barbara P. Yawn, MD, MSc, FAAFP: I think we’re also quite unrealistic about believing that the patient hears everything that we say.
James F. Donohue, MD: Oh, yes, exactly.
Barbara P. Yawn, MD, MSc, FAAFP: They’re in my office for 12 minutes, if I’m really lucky. And in 12 minutes, I have to discuss 3 conditions with them. Do you think that they heard or were able to hear what I said after the first 30 seconds? Probably not. It is really difficult to absorb all of that and translate it into what it means for your life. So, there are opportunities for education in their home—recurrent education.
One of the things that I just learned about recently is something called VID Scripts. In this, you can record things that you tell patients multiple, multiple times—like how to use the inhalers. They can get it online, through YouTube. But, it’s me, their physician, recording it. Instead of watching Byron show them how to do it, and they’ve never seen Byron before, they go on YouTube and watch me. You can do this for all kinds of things in your practice. Also, I think we need to start using, as you said, social media.
Transcript edited for clarity.