Monday, June 29, 2020

A graduation address for the COVID-19 era

If you watched your child graduate this year, as I did my older son's junior high school ceremony at the end of May, you most likely did so online. The same for my participation in the virtual graduation ceremony for Georgetown University School of Medicine's Class of 2020, which included 17 family physicians who start their internships in July. Two years ago, I was inspired to write about Dr. Atul Gawande's moving graduation address to UCLA's newest physicians. This year, I turn the clock back to 2012, when Dr. Don Berwick addressed Harvard Medical School's graduating students; his speech later appeared as an essay in JAMA's A Piece of My Mind.

Dr. Berwick, as longtime readers of Common Sense Family Doctor know, is one of my heroes. I finally had the opportunity to meet him in person in early March, when he delivered the Georgetown University School of Nursing & Health Studies Values Based Lecture. He recently captured the essence of that talk about the "Moral Determinants of Health" in another JAMA essay that is well worth reading, but in this post I will focus on "To Isaiah," his Harvard graduation address from eight years ago.

Isaiah is the name of one of Dr. Berwick's past patients, a Black teenager from the Roxbury neighborhood of Boston who developed acute lymphoblastic leukemia and received the "the best of care ... the glory of biomedical science," including chemotherapy and a curative bone marrow transplant. But biomedical science - then and now - proved to be no match for poverty and despair:

Isaiah smoked his first dope at age 5. He got his first gun before 10, and, by 12, he had committed his first armed robbery; he was on crack at 14. Even on chemotherapy, he was in and out of police custody. For months after his transplant he tricked me into extra prescriptions for narcotics, which he hoarded and probably sold. Two of his five brothers were in jail—one for murder; and, two years into Isaiah's treatment, a third brother was shot dead—a gun blast through the front door—in a drug dispute. ...

His world was the street corner and his horizon was only one day away. He hated it, but he saw no way out. He once told me that he thought his leukemia was a blessing, because at least while he was in the hospital, he couldn't be on the streets. And Isaiah died. One night, 18 years after his leukemia was cured, at 37 years of age, they found him on a street corner, breathing but brain-dead from a prolonged convulsion from uncontrolled diabetes and even more uncontrolled despair. ...

Isaiah, my patient. Cured of leukemia. Killed by hopelessness.

Dr. Berwick went on to tell HMS's Class of 2012 that Isaiah's story demonstrated that they had two duties as new physicians. One, to "go to the mat" for their patients, always putting their needs first and advocating for health care to be recognized as a human right in the United States. The second duty was "more subtle - but no less important":

Maybe this second is not a duty that you meant to embrace; you may not welcome it. It is to cure, not only the killer leukemia; it is to cure the killer injustice. ... One million American children are homeless. More people are poor in the United States today than at any other time in our nation's history; 1.5 million American households, with 2.8 million children, live here on less than $2 per person per day.

I am not blind to Isaiah's responsibilities; nor was he. He was embarrassed by his failures; he fought against his addictions, his disorganization, and his temptations. He tried. I know that he tried. To say that the cards were stacked against him is too glib; others might have been able to play his hand better. I know that; and he knew that.

But to ignore Isaiah's condition not of his choosing, the harvest of racism, the frailty of the safety net, the vulnerability of the poor, is simply wrong. His survival depended not just on proper chemotherapy, but, equally, on a compassionate society. ... Isaiah, in his legions, needs those in power—you—to say to others in power that a nation that fails to attend to the needs of those less fortunate among us risks its soul. That is your duty too.

Our nation's health care professionals have been "going to the mat" to treat patients with COVID-19 for the past four months. In doing so, hundreds have already lost their lives. To their credit, the Congress and the President rapidly enacted legislation to reduce obstacles to coronavirus testing and care created by our patchwork health care system, where at least 27 million are uninsured and tens of millions with insurance still cannot afford to see a doctor or pay for essential medications. Thus far, there has been no similar national initiative to eradicate injustice, even as millions have peacefully protested incidents of police violence and people of all races, from all places, have signaled support for the Black Lives Matter movement.

Doctors have participated in many protests, leading some to label them hypocrites because of the real possibility that the protests could accelerate COVID-19 community spread (though early findings from Washington State suggest that their contribution has been minor as compared to indoor social gatherings without masks). Thus far, the Washington, DC metro area is one of few in the country that has seen a sustained decline in cases despite large protests and tear gassing of protestors. But as imposing a public health problem COVID-19 remains, it pales in comparison to the morbidity and mortality toll of racism, social injustice, institutionalized inequality, and poverty - all factors which have fed the pandemic and contributed to the disproportionate devastation the virus has caused in communities of color. To respond to Dr. Berwick's "second duty," it is absolutely right and appropriate for all physicians to take a knee against injustice, and to use the power of our medical degrees to make our political representatives "go to the mat" for the most vulnerable Americans.

Wednesday, June 24, 2020

Artificial intelligence in primary care: progress and challenges

As applications of artificial intelligence (AI) in health care multiply, AI-enabled clinical decision support is coming to primary care. For example, a recent article in the Journal of Family Practice discussed applications of machine learning (ML) software to screening for diabetic retinopathy (DR) and colorectal cancer, and a study in the Journal of the American Board of Family Medicine utilized ML to create a new clinical prediction tool for unhealthy drinking in adults. Although research on primary care AI remains limited in scope and diversity of authorship, Drs. Winston Liaw and Ioannis Kakadiaris argued in a Family Medicine commentary that appropriately guided, such research could help preserve the parts of primary care that physicians and patients value most:

The digital future is not a passing trend. We will not return to paper charts. The volume of information we are expected to manage will not decline. Without a strategy for our digital present and future, our specialty risks being paralyzed by data, overwhelmed by measures, and more burned out than we already are.

We can define our future, by embracing AI and using it to preserve our most precious resource—time with patients. Adaptation to this new reality is key for our continued evolution, and AI has the potential to make us better family physicians. ... For AI to elevate the practice of family medicine, family medicine needs to participate in relevant design, policy, payment, research, and delivery decisions.

Evaluation and implementation of AI-based clinical approaches is challenging. In addition to being externally validated and corrected for biases, ML models should be transparent about data sources and assumptions and quantify and communicate uncertainty. In addition, involvement of clinicians in model building and adoption into clinical decision support systems is essential.

In the Diagnostic Tests feature in the March 1 issue of American Family Physician, Dr. Margot Savoy reviewed an application that adheres to all of the best practices for AI in primary care. IDx-DR, a software program that uses AI to analyze retinal images from an automated nonmydriatic camera, is approved by the U.S. Food and Drug Administration for DR screening in adults 22 years and older. In a prospective study of 819 adults with diabetes recruited from 10 primary care practices, IDx-DR correctly identified 173 of the 198 patients with more than minimal DR according to the reference standard.

In a separate project, Google Health researchers evaluated the implementation of a deep learning algorithm for DR detection in 11 clinics in Thailand, a country with low screening and early treatment rates due to a shortage of ophthalmologists. Unexpected issues arose, according to an article in the MIT Technology Review:

When it worked well, the AI did speed things up. But it sometimes failed to give a result at all. Like most image recognition systems, the deep-learning model had been trained on high-quality scans; to ensure accuracy, it was designed to reject images that fell below a certain threshold of quality. With nurses scanning dozens of patients an hour and often taking the photos in poor lighting conditions, more than a fifth of the images were rejected.

Patients whose images were kicked out of the system were told they would have to visit a specialist at another clinic on another day. If they found it hard to take time off work or did not have a car, this was obviously inconvenient. Nurses felt frustrated, especially when they believed the rejected scans showed no signs of disease and the follow-up appointments were unnecessary.

Like all primary care tools, the way that AI-enabled decision support is implemented in real life will contribute as much to its success or failure as test results under optimal conditions.


This post first appeared on the AFP Community Blog.

Thursday, June 18, 2020

Less medicine, more health? COVID-19 pandemic provides a natural experiment

One of my favorite health care books of 2015 was Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care, by Dr. Gil Welch, a general internist who was then a health services researcher at Dartmouth. After resigning his position at the college in 2018 in the wake of an at-best-questionable accusation of plagiarism, he joined the Center for Surgery and Public Health at Brigham and Women's Hospital and has continued to produce excellent work, including an insightful analysis of prostate cancer mortality trends and more recently, a CNN opinion piece with Dr. Vinay Prasad about "the unexpected side effect of COVID-19." In their CNN piece, Welch and Prasad pointed out that the much lower utilization of the U.S. health care system during the pandemic has provided a unique opportunity to for researchers to examine if certain high-volume medical interventions (e.g., physicals, cancer screenings, orthopedic surgery, and surgery for low-risk cancers) actually improve health outcomes:

After Covid-19, if we dare imagine the day, it will be important to ask who was harmed by delayed and forgone medical care. But the severe financial strains on individuals and public budgets make it just as essential to ask who benefited from avoiding interventions with no salutatory effect. ... Covid-19 provides a once in a lifetime opportunity to study what happens when the well-oiled machine of medical care downshifts from high to low volume in order to focus on acutely ill patients. It will be comfortable for physician researchers to study what was lost. It will be courageous for them to study what was gained.

If a physical necessarily includes laying hands on patients, I haven't done one in more than 3 months, as my practice has shifted almost entirely to telehealth. To tell the truth, I haven't missed these physicals much. I've long been a skeptic of the value of a general health checkup in adults, even though in our fee-for-service payment system they are essential to primary care practices paying the bills (and their absence has led to many practices facing bankruptcy as the pandemic grinds on). It's not just that physicals are often a waste of time and money, though - sometimes, they can even be harmful.

In a 2014 JAMA essay that was re-published in this year's theme issue marking 40 years of of "A Piece of My Mind," Dr. Michael Rothberg recounted the near-fatal cascade of testing that began with his 85 year-old father's checkup with a new primary care physician. This doctor, who felt a possible aortic aneurysm on the abdominal examination, ordered an ultrasound scan (which revealed no aneurysm, but saw something in the pancreas), followed by a CT scan (which revealed a normal pancreas, but saw a lesion on the liver), followed by a liver biopsy that revealed a hemangioma, a benign but extremely vascular tumor that bled profusely and required the transfusion of 10 units of blood. He spent a painful week in the hospital not being able to urinate without a catheter and received a $50,000 bill for his troubles - inspiring the essay's title, "The $50,000 Physical."

I could tell you several similar stories of testing cascades that went wrong from my own decade-and-a-half in practice; probably every general internist or family physician who isn't fresh out of residency has at least one. Of course, no organization recommends screening for an aortic aneurysm in a healthy 85 year-old man, but no one recommends ordering a chest x-ray or electrocardiogram at a physical either, or doing a Pap smear in a woman younger than 21 or older than 69, and these "low value" (really, "no value") screening tests still happen far too often. A retrospective cohort study published last week in JAMA Internal Medicine found that adults in Ontario who received those 3 particular tests ended up having significantly more subspecialist visits and subsequent (likely unnecessary) diagnostic tests or procedures in the next 90 days.

"De-implementation" is the formal health services research term for "figuring out how to do fewer things to patients that do more harm than good." Just as COVID-19 has accelerated an overdue transition to providing more health care virtually, I hope that it will also inspire researchers to "study what was gained" from postponed or cancelled appointments with family doctors and surgeons. If the pandemic has a silver lining, this might be it.

Sunday, May 31, 2020

An epidemic of inequality

On June 23, 1982, when I was six years old, Vincent Chin, a Chinese American resident of Michigan celebrating his bachelor party with friends, was bludgeoned to death with a baseball bat by two white men. Ronald Ebens and stepson Michael Nitz, auto workers who had both been affected by competition from Japanese companies (Nitz had been recently laid off), hurled racial slurs at Chin, whom they mistook for being of Japanese descent. Both men were charged with second-degree murder and pleaded guilty to manslaughter, which typically carries up to a 15 year jail sentence. Instead, Judge Charles Kaufman fined them a total of $3000 and sentenced them to 3 years' probation, stating in a letter that "these weren't the kind of men you send to jail."

Outraged Asian Americans in the Detroit metro area and around the nation took to the streets to protest the verdict. As documented in the final episode of the PBS documentary "Asian Americans," this senseless murder was a particularly bitter pill for Asian Americans to swallow; after a century of being labeled the "model minority" and doing everything we could to blend in, we were in fact still viewed by most whites as "perpetual foreigners."

Chin's family eventually brought federal civil rights charges against Ebens and Nitz, the first time that this statute had been used for a hate crime against someone other than African Americans. Although Ebens was sentenced to 25 years in prison, the verdict was overturned on appeal. Chin's mother Lily, who died in 2002, was quoted as saying: "What kind of law is this? What kind of justice? This happened because my son is Chinese. If two Chinese killed a white person, they must go to jail, maybe for their whole lives... Something is wrong with this country."

Something is still wrong with this country. Although reported hate crimes against Asian Americans had been declining since 2003, and in 2017 were a small fraction of the number reported against black, Muslim, and Jewish Americans, this changed with the arrival of COVID-19. Fueled by politicians throughout March calling SARS-CoV-2 the "Chinese virus," Chinese Americans, and other Americans of Asian descent who are confused with being Chinese, have increasingly been the targets of racist tirades and worse as the pandemic spread throughout the U.S.

Meanwhile, in the words of a Medscape commentary, COVID-19 has "unveiled a tale of two Americas," as it has ruthlessly exploited entrenched health disparities in black and Hispanic Americans who have long suffered the effects of structural racism. Nationally, black Americans are three and a half times more likely, and Hispanic Americans twice as likely, to die from COVID-19 than white Americans. You can see this on a local level in the District of Columbia, where the largely minority-populated Northeast and Southeast quadrants have had many more cases diagnosed than the largely white Northwest quadrant, and black residents (who comprise just 46% of the population) have suffered a stunning 86% of the deaths. As Ed Yong wrote in his latest article in The Atlantic:

Vulnerability to COVID-19 isn’t just about frequently discussed biological factors like being old; it’s also about infrequently discussed social ones. If people don’t have health insurance, or can afford to live only in areas with poorly funded hospitals, they cannot fight off the virus as those with more advantages can. If people work in poor-paying jobs that can’t be done remotely, have to commute by public transportation, or live in crowded homes, they cannot protect themselves from infection as those with more privilege can. These social factors explain why the idea of “cocooning” vulnerable populations while the rest of society proceeds as normal is facile. That cocooning already exists, and it is a bug of the system, not a feature. Entire groups of people have been pushed to the fringes of society and jammed into potential hot zones.

Thousands of Americans have taken to the streets this weekend to protest the murders of George Floyd and Ahmaud Arbery by Minnesota police officers and self-appointed vigilantes, respectively. Whether the offenders will receive punishments commensurate to these crimes, or if they will be let off with slaps on the wrist, like Ebens and Nitz in 1982 or George Zimmerman in 2013, remains to be seen. But in a larger sense, the protests are about more than simply the unjust deaths of individuals. They are about the continuing tolerance of too many Americans to fatal inequalities in our systems of justice, housing and health care that stack the deck against persons of color and rob them of more than a decade of life. Whether it's the President of the United States repeatedly lying about the impact of COVID-19; the closing of essential hospitals in underserved minority or rural communities; or a modern-day epidemic of amputations in black Americans in Southern former slave states; these protests are an expression of deep-seated rage about an epidemic of inequality that men and women in power have long minimized, dismissed or ignored.

Wednesday, May 27, 2020

Multisystem inflammatory syndrome associated with COVID-19 in children

One of the few comforting findings in the COVID-19 pandemic has been that most children older than one year of age have a less severe clinical course than adults. A large case series from China suggested that about half of infected children have mild symptoms (acute upper respiratory tract infection or gastrointestinal symptoms, including diarrhea) while only 1 in 20 develop hypoxia, respiratory failure, or other organ failure. In a U.S. case series, two-thirds of infants younger than 12 months were hospitalized; the corresponding figure in older children was 5 to 15 percent. As a pediatric infectious diseases specialist at New York University told a New York Times reporter, "The idea that children either don't get COVID-19 or have really mild disease is an oversimplification."

On April 7, Hospital Pediatrics published a case report of a 6 month-old infant who was hospitalized for classic Kawasaki disease and had a positive result on a reverse transcription polymerase chain reaction (RT-PCR) test for COVID-19. At that time, it was not clear if the COVID-19 diagnosis was coincidental or associated with this rare vascular inflammatory condition. On May 7, the Lancet published a report of a cluster of 8 cases of children with hyperinflammatory shock (atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome) who presented to a children's hospital in London during a 10-day period in the middle of April. Within one week, more than 20 children with similar clinical features were admitted to the pediatric intensive care unit (PICU), half of whom tested positive for SARS-CoV-2. Around the same time, reports in a pediatric journal described severely ill children with COVID-19 in Washington, DC and New York City.

In Bergamo, Italy, the incidence of Kawasaki-like disease increased 30-fold between February and April at the height of the epidemic. Compared to a historical group of children with Kawasaki disease prior to the pandemic, these children were older and had a higher rate of cardiac complications. Investigators in France and Switzerland described a series of 35 children (31 of whom tested positive for SARS-CoV-2) who were treated in PICUs for acute heart failure due to a severe inflammatory state.

On May 14, the U.S. Centers for Disease Control and Prevention (CDC) issued an official health advisory to provide information to clinicians about multisystem inflammatory system in children (MIS-C) associated with COVID-19. The case definition for MIS-C is as follows:

- An individual aged < 21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND

- No alternative plausible diagnoses; AND

- Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms.

Fortunately, standard treatment for Kawasaki disease (described in a 2015 article in American Family Physician), including intravenous immunoglobulin, corticosteroids, and aspirin, thus far appears to be effective in treating MIS-C associated with COVID-19.


This post first appeared on the AFP Community Blog.

On June 17, the Center for Health Journalism hosted an informative webinar on MIS-C. A pediatrician spoke for the first 20 minutes about the experience of Washington, DC's Children's National Hospital, followed by noted journalist Pam Belluck answering questions about responsible health reporting on this syndrome.

Wednesday, May 20, 2020

The end of the beginning?

On November 10, 1942, after British forces led by Generals Harold Alexander and Bernard Montgomery decisively defeated a German-Italian army led by the "Desert Fox" (Field Marshal Erwin Rommel), at the Battle of El Alamein in Egypt, Prime Minister Winston Churchill gave a speech where he memorably declared of the war against the Nazis, "Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning."

Although the progress of the fight against the COVID-19 in the U.S. remains, in the words of science writer Ed Yong, a "patchwork pandemic," the numbers of new cases of and deaths from the virus have either stabilized or are heading downward in most states and in the Washington, DC area, while hospital and public health contact tracing capacity has been growing. Practically every state has started cautiously easing restrictions on movement and public places and allowing shuttered businesses to reopen with social distancing measures in place. Although some politicians would like to declare victory over the virus, this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.
After I deployed this Twitter survey, some colleagues in medicine and public health suggested that I had left off some important terms, notably "social distancing," "exponential growth," and "flatten the curve." I agree. Notably, though, all four options received votes, and the top vote-getter, herd immunity, did not quite receive a majority. So I thought I'd provide my perspective, as a family physician and population health teacher, on what each of these terms mean and how they have sometimes been misinterpreted by the general public.

Herd immunity: the concept that once a pathogen has infected a certain percentage of the population (how much depends on how contagious it is) and they have developed immunity, there are fewer susceptible hosts, which not only slows the spread but also indirectly protects non-immune persons. For vaccine-preventable infections like measles and pertussis (which causes whooping cough), herd immunity is especially important for protecting persons who have contraindications to immunization (for example, infants too young to be vaccinated or immune-compromised persons).

However, for COVID-19, some have suggested that rapidly achieving herd immunity should be a national goal, even in the absence of an effective vaccine. They pointed at Sweden, an country that stands alone among developed nations in not instituting an economic lockdown (though mass gatherings have been banned and social distancing is still strongly encouraged). Nonetheless, by early May, only about 25 percent of the population of Stockholm had developed antibodies to SARS-CoV-2 and Sweden currently has the highest per-capita COVID-19 death rate in the world without any perceptible economic benefits. In New York City, in March and April the epicenter of the pandemic in the U.S., a study found that only 1 in 5 people had antibodies to the virus - far short of a herd immunity threshold even though hospitals and morgues were overrun and 1 out of every 400 people died. As Five Thirty Eight calculated, "If the [COVID-19] fatality rate is around 0.5 percent and 70 percent of Americans have to get sick before their immunity starts protecting others, that means more than 1.1 million people would die." Personally, I think that the most likely projection of 140,000 U.S. deaths given existing social distancing measures is a national catastrophe, but 1,100,000 deaths is totally unacceptable.

Quarantine: refers to the isolation of persons who have been exposed to a contagious disease for the maximum duration of the time it takes from the time of exposure to becoming symptomatic. For COVID-19, the recommended duration is 14 days. This is not the same thing as "self-isolation" of persons with known infections or "lockdown" (government-mandated travel restrictions). Yes, I intentionally misused this term in my previous post, but "self-isolation / lockdown reading" just sounded too weird.

Contact tracing: refers to the practice of identifying and contacting persons who have been exposed to a known infected individual so that they can be assisted in quarantining themselves and connected to resources (including health care) if needed. Smartphone tracking apps can help facilitate this process, but are not a substitute for real people working the phones. If you are interested in learning more about becoming contact tracers for your states and communities, Johns Hopkins University is offering an excellent free online course on this topic. For contact tracing to be effective in preventing new COVID-19 outbreaks, however, it is critical that the general population trusts the tracers and adheres to their recommendations. In a widely suspicious community, riled up by armed protests about government encroachment on their freedoms (to travel to one's second home, to work out at the gym, to go bowling, etc.), I worry that many people may ignore public health workers telling them to stay home, and will continue infecting others.

Antibody testing: blood testing for antibodies to SARS-CoV-2 that can help determine if an individual has been exposed to the virus. My colleague Dr. Mark Ebell has pointed out that with current far-from-perfect tests and a low prevalence in most communities (particularly in persons without respiratory symptoms), false positive test results will be common. Most critically, even a "true positive" antibody test result does not guarantee that an individual is protected from COVID-19, or for how long. We just don't know yet how durable immunity is or how long it lasts. So if you get a blood test that suggests you have antibodies, don't discard your mask or stop social distancing because you think you can't get infected or infect others.