Yes, PCPs can help youth with smoking, but can we get incentives to align?

Teen girl smoking cropped-shutterstock_108536432Claire McCarthy, MD, has been a primary care pediatrician and writer for more than 20 years. She blogs for the Huffington Post, Boston.com and the Children’s pediatric health blog, Thriving. She practices at the Children’s Hospital Primary Care Center. Follow her on Twitter @drClaire.

When I read about the report from the U.S. Preventive Services Task Force saying that pediatricians can “move the needle” when it comes to youth smoking, I had a few different reactions.

My first reaction was:  Cool! I don’t want youth to smoke. We all know the health problems it causes. It’s good to know that we can make a difference.

My second reaction, as I thought about it more, was:  Duh. Of course we can make a difference. We primary care pediatricians are perfectly positioned to influence the health behaviors of youth. We have relationships with them and their parents. We see them regularly, we have the opportunity to build trust and to get to know and understand them. We talk to them about all aspects of their health and well-being. While they don’t always listen to us, there’s always the chance they will.

And then, as I thought about it even more, my reaction was:  Is anyone going to help us do it?

The task force didn’t recommend any specific program or approach, but they did describe some successful examples. In one, youth and families attended groups to discuss smoking (seven of them). In another, they watched a 28-minute video and had follow-up calls from a nurse. In another, educational handouts about the risks of smoking were given out in the office.

Um… I don’t know about you, but I can’t make that stuff happen. I mean, I can, but it would take more time, more staff and more money than our practice currently has. Even the handouts cost money.

That’s the thing. I’m glad that everyone is realizing the power and potential of the primary care provider, but there’s only so much we can pull off in a 15-minute visit. I feel like every time I turn around I’m being asked to screen for or do counseling about yet something else… and while each and every one of these initiatives is important and useful, we are rapidly exceeding the possible. And if we pile on the handouts, we just increase the likelihood that they will end up in the trash unread.

We have to think outside our usual boxes and get creative. We are unlikely to get hour-long visits with our patients… so the office visit can’t be where all the screening and education happen. We need to use nurses, health educators and other staff to do some of the work—and we need to think about using the Internet and technology to help us. We need to think about inter-visit care—about using email and apps and video to push information to patients—and get information back.

I’m hopeful that the rise of accountable care organizations and patient-centered medical homes will push this problem to the forefront. If we are to be held accountable for our preventive efforts and outcomes, then real time, energy and ultimately money needs to be put into making our work actually feasible. Just because prevention saves money doesn’t mean that it doesn’t cost money.

Yes, we can move the needle—on smoking, substance abuse, obesity, asthma, diabetes, heart disease and so many other problems. But we’ll need help.