Monday, January 7, 2019

Guest Post: How the medical profession can help heal divisions as well as diseases

Richard Gunderman, MD, PhD, Indiana University

Medicine need not be confined to the role of cultural bellwether, a sheep with a bell on its neck that reveals where the whole flock is headed. Along with other professions such as law, clergy and education, medicine can and should play the leadership role of a shepherd, helping our society to develop more thoughtful, balanced and generous approaches to the challenges that face us. After all, the word doctor means teacher, and our culture needs the best instruction we can offer. The dawn of a new year makes the time ripe for such a shift in medicine’s role.

Doctors as teachers

In serving as educators, doctors have many resources to draw on. They are among the best educated groups in our society, having pursued one of our the longest and most intense courses of study. In practice, they regularly participate in moments that help to clarify what life is all about – birth and death, growth and aging, suffering and relief. And they serve as trusted confidantes and counselors to patients and families at some of life’s most meaningful moments.

Popular culture has reflected an erosion of the doctor as teacher and role model. In the 1960s and 70s, television doctors such as Dr. Kildare and Marcus Welby epitomized virtues such as dedication and compassion. Then along came “M.A.S.H.” and “St. Elsewhere,” which adopted a more irreverent attitude toward medicine and the people who practice it. By 2004’s “House,” which ran for eight seasons, the doctor had degenerated into a clever but deeply misanthropic opioid addict.

First, do no harm

As a physician and educator, I think that, for medicine to help heal our culture, doctors must embrace their role as advocates for principles that have long represented the core of the healing professions. Although “Primum non nocere, or ”First, do no harm,“ does not appear in the writings of the "father of medicine” Hippocrates, it is often cited as medicine’s first principle. And the idea that doctors should avoid harm is part of the modified Hippocratic Oath that most doctors take when they graduate from medical school.

This principle does not imply that doctors should never harm. After all, no surgeon could ever operate and no oncologist could ever administer chemotherapy if they rigorously adhered to it. It means instead that risks and harms must always be balanced against benefits, and that where the balance is too uncertain or unfavorable, it is better to do nothing. More broadly speaking, we should avoid saying things or acting in ways that cause needless injury.

What would “Do no harm” look like in our popular culture? First, it would mean eschewing personal attacks, which seek to label people as unworthy, disgusting, or evil. In public discourse, our goal should be to understand different points of view, to educate one another, and to take the interests of others into account in arriving at decisions. Physicians are expected to take good care of even patients they find disagreeable, and this an outlook sorely deficient in the U.S. today.

Get the whole story

A second habit deeply ingrained over the course of medical training is to recognize that there are usually more than two sides to any question. Suppose a patient complains of pain in the right lower quadrant of the abdomen, a classic symptom of appendicitis. Only poor physicians would confine their attention to the question, “Is it appendicitis or not?” The real issue at hand is to determine what is causing the pain and what needs to be done about it.

In popular culture, complex matters are often reduced to highly simplified dichotomies, in which the two sides are portrayed as sporting white and black hats. It seems as though all Americans need to know is whether a person is a Democrat or Republican, a conservative or a liberal, or a reader of The Washington Post or The Wall Street Journal. In fact, however, making good choices requires an understanding far deeper than which side of a political divide a person is on.

Good doctors learn quickly that a cursory inspection can be deeply misleading, as a story once told by a colleague reveals. An elderly, disheveled, incoherent woman was brought to the emergency room with a broken arm. The staff took her for a homeless person. Later, however, she started to make sense, and provided her phone number. When her family came to pick her up, they arrived in a chauffeured limousine. In this as in so many cases, what first met the eye turned out to be quite deceptive.

Put service before self

To become really good doctors, medical students need to learn something: Patients do not exist to provide careers to physicians; instead, physicians exist to care for patients. Like other professionals, doctors need to put the interests of their patients first. The overarching goal is not to advance the physician’s career, to generate more income, or to secure the business interests of a medical practice or hospital. The goal is to care well for the patient.

The founders of the U.S. knew that human beings are not angels, but they also believed that people can look beyond narrow self-interest and do what is best for others and the larger whole. They knew that serving a purpose beyond self is one of the surest ways to find meaning and purpose in life, and that those who contribute the most often lead the fullest lives. They bet their own lives on the proposition that Americans could answer the call of their better selves.

By serving as exemplars of what a life of service looks like in communities across the country, doctors and other professionals can remind Americans of all ages what human beings at their best are really capable of. To look out only for number one is to lose hope in neighbors, communities and society. To get to know others, to take an interest in their stories, and to reach out and serve when they need help and support is one of the signs of a hopeful, thriving culture.

The idea of medicine as a cultural beacon of goodness may seem profoundly counter-cultural. Our appetite seems much greater for stories of doctors whose financial or sexual misconduct has disgraced themselves and the profession. Yet for the professions to play a role in reshaping our habits of mind and heart, their members must act courageously, not waiting until the cultural winds have shifted but letting their better voices speak even when no one else seems to be listening.The Conversation


This article is republished from The Conversation under a Creative Commons license. Read the original article.

Thursday, December 20, 2018

My favorite public health and health care books of 2018

For the fourth year running, here is a list of the top 10 health-related books I read, ordered alphabetically. Although most were published within the past year, a few older books made it in as well. If you have already read these, feel free to peruse my lists from 2017, 2016, and 2015 for other worthwhile health and medicine reads for the holidays.


1. Bad Blood: Secrets and Lies in a Silicon Valley Startup, by John Carreyrou

What amazed me about this sordid tale wasn't the degree of corporate malfeasance involved, but how a charismatic college dropout managed to dupe so many investors and reporters (except for the author, notably) for so long.

2. Called for Life: How Loving Our Neighbor Led Us Into the Heart of the Ebola Epidemic, by Kent Brantly

Although there have been many excellent profiles of Dr. Brantly, a Texas family physician who survived an infection with Ebola virus during the 2014 outbreak in Liberia, nothing compares to hearing the story in his own words.

3. The Comeback: Greg LeMond, the True King of American Cycling, and a Legendary Tour de France, by Daniel de Vise

Though you'll likely find this biography in the sports section of your local bookstore, it is as much about medicine as cycling: LeMond's remarkable recovery from a nearly fatal hunting accident, as well as the pharmaceutical doping practices that spread through the rest of the peloton in the early 1990s and led to his premature retirement from the sport.

4. The Fears of the Rich, The Needs of the Poor: My Years at the CDC, by William Foege

The compelling memoir of a public health legend who tacked infectious disease threats from Legionnaires disease to smallpox.

5. The Fever: How Malaria Has Ruled Humankind for 500,000 Years, by Sonia Shah

What is by far the deadliest creature in human history? The mosquito.

6. In Shock: My Journey From Death to Recovery and the Redemptive Power of Hope, by Rana Awdish

A critical care doctor became a critical care patient, and after multiple near-death experiences emerged on the other side a more compassionate and capable physician.

7. Next in Line: Lowered Care Expectations in the Era of Retail and Value-based Health, by Timothy Hoff

A management professor explores, through patient and physician interviews, how efforts to standardize and improve primary care quality have instead created an environment that is toxic to the therapeutic relationships that make family medicine effective in the first place.

8. The Public Health Crisis Survival Guide, by Joshua Sharfstein

Dr. Sharfstein, currently Vice Dean and director of the Bloomberg American Health Initiative at Johns Hopkins University (where I earned my Master of Public Health degree), relates war stories and lessons learned from his days as a city, state, and federal health official.

9. Surgeon General's Warning: How Politics Crippled the Nation's Doctor, by Mike Stobbe

As this book illustrates, past U.S. Surgeon Generals have struggled with the high-profile but low-authority nature of the position and the political considerations that shadowed their every public utterance. I'm a fan of the current SG, Dr. Jerome Adams, whose recent declaration that teenage vaping has now reached "epidemic" proportions reminded me of his predecessor, Dr. C. Everett Koop.

10. What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City, by Mona Hanna-Attisha

Dr. Hanna-Attisha's crusade to protect the children of Flint, Michigan from lead-poisoned drinking water represented a rare triumph of the disenfranchised over racial and social injustices. Her family's interweaved immigration story serves as a reminder of what America stands to lose from policies that seek to close our borders.

Monday, December 17, 2018

Family medicine and the value of long-term therapeutic relationships

A commentary in the November 22 issue of the New England Journal of Medicine titled "Beyond Evidence-Based Medicine" received much well-deserved criticism for not only mis-characterizing EBM, but advocating for a novel approach, "interpersonal medicine," that was explicitly codified in the recognition of the U.S. specialty of Family Practice nearly 50 years ago. Here's what the authors wrote about this practice of medicine that is, apparently, new to them but well-known to the rest of us:

Interpersonal medicine would recognize clinicians’ influence on patients and informal caregivers and the relationships among them. It would be anchored in longitudinal, multidirectional communication; broach social and behavioral factors; require coordination of the care team; and constantly evaluate and iterate its own approach.

After reading these sentences via a tweet from Dr. Eric Topol, I quickly added my perspective on "interpersonal medicine," which, judged by the volume of likes and retweets, was greeted enthusiastically by other primary care clinicians and their allies: 

It was one of the few times in recent memory that other physicians were eager to jump on the #FMRevolution bandwagon, as geriatricians, general internists, and general pediatricians tweeted that their generalist fields provide "interpersonal medicine" too. I agree. But I draw the line there. No matter how excellent one's beside manner, a subspecialist whose job description revolves around treating a specific a body part, organ system, or disease state, or intermittent contacts during specific periods of illness (e.g., emergency medicine, hospitalists) is not using the generalist approach described by longtime Annals of Family Medicine editor Kurt Stange in a 2009 editorial:

A generalist approach involves working on the parts while paying attention to the whole; being connected by sustaining relationships; having a broad base of knowledge while being grounded in specific information; scanning and prioritizing, then focusing on what is most meaningful; moving back and forth between the universal and the particular. The generalist approach is rooted in recognizing connection to person, community, and cosmos.

The skills of generalist physicians - and family physicians in particular - have long been devalued by our health system's mechanisms of measuring and paying for clinical work in discrete tasks, rather than for caring for the whole person. The movement toward "paying for performance" has not helped. As Dr. Dhruv Khullar and colleagues observed in a recent JAMA Viewpoint, "because these programs are disconnected from the needs of patients and physicians within organizations, they often result in erroneous metrics, gaming of the system, and unidirectional assessments that emphasize meeting thresholds over open dialogue."

In other words, never mind that I carefully reviewed with my 65 year-old patient of the past 5 years with a recent blood pressure of 145/92 the pros and cons of intensifying his medication regimen, the limitations of the evidence, and his personal values and preferences; 140/90 is my practice's non-negotiable cutoff for poor quality. This is hardly surprising, since quality management has rarely accounted for what makes a difference to patients in primary care - particularly, as Dr. Justin Mutter and colleagues suggested in "Core Principles to Improve Primary Care Quality Management," prioritizing therapeutic relationships over time. Reflecting on changes in the role of the personal physician since the dawn of the specialty, a group of senior leaders in academic family medicine has observed:

We have watched our patients age with us. They beg us not to retire. For our patients, we are caregivers, healers, advisors, friends, and navigators through a complex system. Our patients are admirable human beings who taught us our craft, offering clinical challenges and providing us with the gratification that makes practicing medicine worthwhile. A principal challenge for the present and future ... is to be able to establish and maintain the long-term trusting relationships that have characterized family doctors and our role in health systems and society.

In a similar ode to continuity of care, Dr. Adam Cifu, a general internist who has cared for the same patient panel for more than 20 years, wrote in JAMA Internal Medicine: "In our own practices and in our roles engineering health care systems, we should prioritize the maintenance of these relationships. We are losing much more than easy clinic days as we foresake long-term physician-patient relationships." This assertion is not merely anecdotal, but supported by evidence: a recent analysis of Medicare data by Dr. Andrew Bazemore and others at the Robert Graham Center found that higher primary care physician continuity is associated with lower costs and hospitalizations. At the same time, one of my colleagues notes that insurers are paying five times as much for patients to have a video or telephone visit with a "teladoc" than with their family physician.

Enough with "interpersonal medicine"! EBM is not the problem, and it never has been. Rather, the patient experience in the U.S. will not improve without first recognizing that family physicians and other generalists have expertise in whole person care, grounded in long-term therapeutic relationships. Then, policymakers must create conditions that support providing generalist care from the continuum of medical training through clinical practice.

Tuesday, December 11, 2018

Just released from prison? Good luck finding a primary care physician.

A young man with schizophrenia, opioid use disorder (OUD) and chronic hepatitis C infection completed a 5-year prison sentence and was discharged back into the community. While he was incarcerated, he received antipsychotic medications and periodic laboratory monitoring of his liver disease; medication-assisted treatment for OUD was unavailable. At the time of his release, he was given a 30-day supply of pills and told to follow up with a primary care physician. The next few weeks will be a critical time for this patient's health, according to an article on care of incarcerated patients in the November 15th issue of American Family Physician:

Most inmates are discharged from correctional facilities without a supply of medications or referrals to primary care, mental health services, or substance abuse treatment. Lack of care coordination directly affects the health of former inmates. In the two weeks following release, former inmates are 129 times more likely to die of a drug overdose and 12 times more likely to die of any cause than members of the general public.

Former inmates face two significant obstacles to accessing primary care: affording care, and the reluctance of some clinicians to accept formerly incarcerated patients. Before 2014, an estimated 80 percent of incarcerated persons lacked health insurance or the financial resources to pay for basic health care. Even after the expansion of Medicaid to single and childless adults earning up to 138% of the federal poverty level in 36 states and the District of Columbia, many patients continue to slip through the cracks. A 2016 Kaiser Health News article recounted the case of Ernest, a man with severe mental illness who served prison time in Indiana for killing his 2 year-old daughter during a psychotic delusion. Even though Indiana had expanded Medicaid by the time of Ernest's release and set up a system to enroll all eligible prisoners, records show that he was forced to enroll in the program on his own, wasting valuable time and delaying his transition of care:

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled. “Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Having health insurance does not necessarily mean that a patient will be able to access care, as illustrated in a recent Canadian study published in the Annals of Family Medicine. Researchers posing as prospective patients telephoned all family physicians listed as accepting new patients in British Columbia. The only difference between the patient roles was that one set mentioned that he or she had been released from prison a few months before. Among the 250 family physicians who answered the phone and were still providing primary care, control patients were twice as likely to be offered an appointment compared to persons recently released from prison (absolute risk difference = 41.8%).

In 2017, I co-authored a position paper on Incarceration and Health for the American Academy of Family Physicians that suggested "family physicians can promote the health of individuals during the transition from correctional facilities to the community by supporting reentry processes that begin prior to release; collaborations between prison and community health services; integrated models of care; and linkages to housing, employment, and mental health support." To that, I would add that we should not discriminate against patients with a history of incarceration.


This post first appeared on the AFP Community Blog. Via responses on Twitter, I was pleased to learn that some family physicians prioritize appointments for these vulnerable patients.

Wednesday, December 5, 2018

Lowering cholesterol with a statin - when is it worth it?

Although I have never been a big fan of modeling studies, viewing their appropriate role as hypothesis-generating rather than clinical decision-supporting, a study published yesterday in the Annals of Internal Medicine deserves kudos for trying to do what neither the American College of Cardiology/American Heart Association nor the U.S. Preventive Services Task Force did in their respective guidelines on primary prevention of cardiovascular disease for adults aged 40 to 75 years: empirically assess the balance of benefits and harms of statins. (In case you missed it, I recently recorded a Medscape commentary on the 2018 ACC/AHA guideline, which has flaws but overall represents an improvement over the 2013 version.)

In persons at low risk of having a heart attack or stroke, the harms of statins offset (or may be greater than) the benefits, but at what 10-year risk threshold do the benefits begin to outweigh the harms (positive net benefit)? In 2013 and again in 2018, the ACC/AHA proposed an arbitrary threshold of 7.5%, and the USPSTF's slightly higher threshold of 10% is just as arbitrary, even as it compensates for the tendency of the Pooled Equations risk calculator to overestimate true risk and potentially lead to unnecessary therapy. But neither group quantitatively weighed the relatively low probability of preventing a serious cardiovascular event against the higher probability of causing muscle aches, diabetes, and other adverse effects, as this research team did.

The modeling study's results will appeal to patients (including my own) who would prefer that their physicians be conservative in prescribing statins, suggesting that in men the risk threshold where benefits exceed harms ranges from 14% to 21%, while in women it ranges from 17% to 22%. The study's methods are not particularly transparent, relying in part on a network meta-analysis that is not yet published. Even if the model's inputs were clearer, there is no consensus that several of the harms that they attribute to statins (hemorrhagic stroke, renal dysfunction, cancer, and cataracts) are actually medication-related.

Setting the numbers aside, I agree with one general conclusion: although the risk of having a heart attack or stroke rises with age, so, too, does the threshold when it makes sense to take preventive action. Side effects of statins are more common in older persons, and the older you are, the more likely you are to die from something other than cardiovascular disease (so-called "competing causes of death"). Over age 75, it becomes very unlikely that starting or continuing a statin for primary prevention will do more good than harm.

Monday, November 26, 2018

Out-of-hospital management of low-risk patients with acute pulmonary embolism

I've practiced family medicine long enough to remember when treatment of any patient with acute deep venous thrombosis (DVT) required hospitalization for several days administering intravenous unfractionated heparin and oral warfarin while waiting for the patient's international normalized ratio (INR) to reach a therapeutic level. Thanks to the development of low molecular-weight heparins and direct-acting oral anticoagulants (DOAC), outpatient treatment of uncomplicated DVT is now the norm. But patients with newly diagnosed pulmonary embolism (PE) are still typically hospitalized, since they often have hemodynamic instability or other potentially life-threatening conditions.

According to a 2017 article in American Family Physician, the American College of Chest Physicians suggests considering outpatient treatment of acute PE "if the risk of nonadherence is low and the patient is clinically stable; has no contraindications to anticoagulation, such as recent bleeding, severe renal or liver disease, or platelet count of less than 70; and feels capable of managing the disease at home." A recent Point-of-Care Guide reviewed clinical decision tools that predict mortality in patients with newly diagnosed PE. The simplified Pulmonary Embolism Severity Index (sPESI) stratifies patients into low and high risk categories. Low risk patients have a 30-day mortality rate of 1%, while high risk patients have a 9% mortality rate.

A prospective cohort study published in CHEST earlier this year enrolled 200 consecutive adults with newly diagnosed PE and a low risk of mortality using the related Pulmonary Embolism Severity Index (PESI). Participants were observed in the emergency department (ED) for 12 to 24 hours, then treated with anticoagulant medications in the outpatient setting (173 patients were treated with DOACs). After 90 days, no patients had died or suffered a recurrent venous thromboembolism (VTE). One patient had a major bleed after a traumatic thigh injury that required a blood transfusion and surgery.

A pragmatic controlled trial in Annals of Internal Medicine evaluated the effect of implementing an electronic clinical decision support system (CDSS) that included the PESI tool and an educational intervention on decision making for patients with acute PE in the 21 community EDs of Kaiser Permanente Northern California. 10 EDs received access to the CDSS and in-person education and feedback from an onsite emergency physician-researcher ("study champion"); the other 11 EDs served as control sites. The primary outcome was discharge to home from the ED or an ED-based outpatient observation unit. At the intervention sites, home discharge increased from 17.4% to 28%, while there were no changes in discharge practices at control sites. The intervention was not associated with increases in 30-day major adverse events (recurrent VTE, major hemorrhage, or all-cause mortality).

One day, one of my trainees will be able to write, "I've practiced family medicine long enough to remember when even low-risk patients with acute PE required hospitalization ..."


This post first appeared on the AFP Community Blog.